Clinical Case Manager DE Long Term Services & Support-Private Duty Nursing

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

The Clinical Case Manager assists members who are eligible for LTSS in obtaining the services they need as required by DSHP Plus LTSS in New Castle county. He or she contributes to the LTSS case management process by performing telephonic and/or face-to-face assessments for the identification, evaluation, coordination and management of member’s needs, including physical health, behavioral health, social services and long term services and supports. This position is also responsible for completing Level of Care Redeterminations for home and community based members annually. This requires clinical review when evaluating the need for a member to remain in the program. The Clinical Case Manager will also provide clinical support to his/her non-licensed counterparts and may act as a secondary case manager when a member is experiencing an acute episode.

• Coordination of care for medically complex LTSS Members receiving private duty nursing (PDN)
• Performs follow-up on outstanding items of need and maintains a calendar or PDN Coverage.
• Establish communication method to effectively communicate with multiplePDN agencies and member/member representative.
• Coordinates and collaborates with prior authorization team to make sure all necessary precertifications for required services are submitted for review. Assists in obtaining the Letter of Medical Necessity (LOMN) as needed
• Coordinate with provider network team in the utilization of non-contracted providers or facilities as necessary following the single case agreement (SCA) process
• Conducts reevaluation of level of care annually or more frequently as needed in accordance with DSHP Plan Plus LTSS requirements.
• Provides clinical support to non-licensed case managers as needed.
• Conduct condition specific assessments with members with chronic conditions. Provide education and routine follow-up with member.
• Perform initial clinical assessment of new members, develop care plan, and initiate services.
• Facilitate person-centered planning team meetings to coordinate care and services. Identify, coordinate, and assist participants in gaining access to needed LTSS and other Covered Services, as well as non-covered medical, social, housing, educational, and other services and supports.
• Provides information to participants and conducts monitoring of authorized services and supports for Participants.
• Informs participants about available LTSS required needs assessments, the care plan process, service alternatives and service delivery options.
• Informs participants of their rights and responsibilities as well as assists with the complaint, grievance, and DHS Fair Hearing process.
• Collects additional necessary information, including participant preferences, strengths, and goals to inform the development of the Plan of Care.
• Conducts comprehensive needs assessments annually or more frequently as needed in accordance with requirements.
• Review and acting upon worklists in Jiva, including monitoring of new members
• Authorize urgent services when needed
• Monitoring critical incident reporting/documentation, recommending/taking action w/ other corporate entities as required
• Liaison activities with Physical health Care Coordination program

• Working with LTSS and DSNP members to complete comprehensive assessments, care plans, medication reconciliation, monitoring follow-up and progress, and assisting with discharge planning/transitions of care.

Education/Experience:

• Delaware licensed RN required.
• Ability to travel throughout entire state of DE.
• Valid driver’s license required
• Knowledge of the home and community-based service system and how to access and arrange for services
• Experience conducting LTSS needs assessments and monitoring LTSS delivery
• Ability to provide informed advocacy
• Ability to interact with members face to face
• Ability to interact with health care professionals in a professional manner

• Ability to travel up to 75%

• Duties may include case management responsibilities based on business needs. This role is also a part of the contingency plan, where a caseload may be assigned in the event of a staffing need

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.